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HomeMy WebLinkAbout15637 (20) �. . , � -" ' _1��_ CITY OF DIAMOND BAR � s DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 �-w � PRESS ;, ,,, (909)860-3195 Fax(909)861-3117 �o�° BUILDING PERMIT APPLICATION �� FIRM�Y � JOBSITE APPLICATIO y�!� PERMIT P/C o ADDRESS �--� Z-`� ..�.�/c�/,�a� �iQ�z=.� DATE � � v� NUMBER � # c� ISSUE TYPE OCC APN LOT 7RACT DATE 8 CONST. GROUP p OWNER W�NC LL ADDRESS ZONING SETBACKS � CITY ZIP TEL. REORT RW C�7 APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACYOFi SIDE p� ADDRESS PROPOSED USE ` � CITY ZIP TEL. - � wo ARCH/ENGf � � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS ST�RIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION Q OWNER-BUILDERDECLARATION SFR/ADD/REM 6,7j[� O � I HEREBY AFFlPoN UNDER PENALT/OF PEP.JURY THAT I AM EXEMPT FROM THE CONTRqCTORS U- � Garage/Carpart W CENSELAWFORTHEFOLLOWINGPEASON�SEC.7031.58USINESSANOPROFESSIONSCODE:FNVCITYOR C.� CpUNTYWHICHREOUIRE5AP6iMtTTOCOiJSTRUCT,AI,TERIMPROVE,OEMOUSH,ORREPNRANYSTRUP W pdfiD/DeCk � TURE.PRIOR TO ITS ISSUlWCE.ILLSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w S7ATEGENT THA7 HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS l4 � CENSE LAW(CHAPTER 9�COA/MENCINO`MTH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AN�PqD� � Pool/Spa FESSqNS CODE)OR THAT HE OR SHE IS EXEMIPT THEREFROM ANO THE BASIS FORTHE AILEGED E%EMP� TION.ANVVIOLATIONOFSECTION7031.SBYMlVAPPLICANTFORAPERMITSUBJECTSTHEAPPUCANTTO Z pe-Roof � ACMI PFNALTY OF NOT MORE THAN FNE HUNOREO�OIURS(SSaO).): � ❑I,ASOWNEROFTMEPROPERTY,OpMYEMPLOYEESWITHWAGE3ASiHEIR50LECOMPENSATION, � Commarcial - WILL DO THE WORK,AN�7ME STRUCTURE IS NOT INTENDED OP OFFEREO FOR SALE(SEC.7oa4,BU51� J NE55 AND PROFESSIONS WfJE:THE CONTRACTORS LIGENSE IAW DOES NOT APPLY TO AN OWNER OF y PROPEFttVW1�OBUILDSORIMPROVESTHEREON,ANDNHODOESSUCHWORKHIMSEIFORHERSEIFOP = � THROUOM HIS OR HER ONM EMPLOVEES,PROVIOED THAT SUCH IIdPROYEMENTSAPE NOT INTENOEO OR m 0 ,OFFEREDFORSPLEIF.HOWEVEFi.TiEBUIIDMGORIMPROVEM�liI550LDWITHINONEVEAHOFCOMPIE� Z TION,THE�N1NERbUILL1ER WILL HAVE THE Bl1RDEN OF PROVIN6 THAT HE OR SHE DID NOT BUILD OR = IMPROVEFONTHEPURCOSEOFSALE). W ❑I,ASOWNEROFTHEPROPERT',AAIEXCLUSIVELYCANtRACTINOWfTHIICENSEDCOMRACTORS (r TO CQMSTRUCT THE�FIWECT�SEC.704/,OUSINESS ANO PROfE5S10N5 CADE:THE CONTRACTOPS LI- V3I118IIOf1 ADJ.AREA W CENSEUWDOESNOTAPPLY70ANOWNEROFAPROPER7YWFIOBUILDSORIMPROVES7HEREON,AND � WFIOCONTRACTSFOq3UCHPROJECTSWITHACONTRACTOF(S)LICENSEDPURSUANTTOTNECONTRAG �UANTITY DESCRIPTION FEE � 7DRSUCENSEUW.). J Q ❑I AM EXEMPTUNOER SEQ ^_ B.h P.Q FOR THIS REASON Q 3 � � � OATE _OWNER U W � UCENSED CONTRACTORS DECLARATION W 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENS'cD UNOER PROVISIONS OF CHAPTER � p� Y(COMMENGINC�W1TH SECTION 7000)OF OIVISION 3 OF THE BUSINE55 ANp PROFESSIONS CODE,AtiD z �X MY LICENSE IS IN FULL FORCE ANO EFFECT. m � IICENSE CUSS IIC.NO. j J V DATE CONTIiACTOR d LiJ � WORKERS'COMPENSATION DECLARATION Q � I HEREBY AFFIRM UNDER PENALTV OF PERJ4RY ONE OF THE FOLLOWING OEGLARATIONS: � � Z Q O _IHAVEAN�WILLMAISJTAINACEpTIFICATEOFCONSENTTOSELF-INSUREFOFWORKERS' 2 � COAIPENSATION,AS PHOVIDED BV SECTION 370o OF THE 1A80R CO�E,FORTHE 7ERFORIAANCE U OFTHE WORK FOfi WHICH THIS PERMiT IS ISSUED. � T � � _IHRYElN1DWll1MAINTAINWORKERS'COMPENSATIONINSURANCE,ASRE4UIREOBYSECTION � /�,� / d� 370oOF7HFLABORCODE,FORTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS � �6' � � ISSUED.MY WORKERS'CCMPENSATION WSURANCE CARRIERAND POLICv NUMBERARE: CONSTflUCTION ���" � CARRI'cR PLAN REVIEW � � "! — Z va.ICYNUneEP__ _ ELECTRIC 4 0 (IHISSEGTqNNE�NOTBECAMA.EfEDOF7HEPEP7.YTI5FORaVEHurAftEUOG1AR5(btao)ORLESS�. PLUMBING _ � I CERTIFVTHAT M7NE PERFORMANCE OFTHE WOPK FOR WHtCHTHiS PERMIT IS ISSUEO,I MECHANICAL �J SHAIL NOT EMPLOYANY PERSON IN ANY IAANNER SOAS TO BECOME SUBJECTTO THE � WORKERS'COMPENSATION LAWS OF CALIFORNI0.AND AGREE THAT IF I SHOUI�BECAME INSPECTION FEE � S SUBJECTTOTHEWORKERS'COMPENSATIOUPftCVISiONSOFSECTION37o00FTHELABOR CODE,I SHALL FORTHWI7}i GOMPLY WITIi THOSE PROVIS'iONS. �SSUANCE -� � SMIP 0 �ATE: __ APPLICANT. , � ENERGY P/C ' J WARNINO:FAILURE?O SECURE WORKERS'COMPENSATION CAVEFiAGE IS UNUIWFUL,AND SHAII BE � � SUBJECTANEMPLOYERTOCRIMINALPENlaTIESANDCiVILFMESUPTODNEHUNOREDTHOUSAND ENERGYPERMIT � � �- �$p �OlLARS(iico,000).IN ADDITION TO THE CAST OF COMPENSATION,DAMAGES AS PROVIDED FOF I� �„ ���,—_"–'9� J SECTION37oBOFTHEU80aCODE,INTEREST,ANDATTORNEI^SFEES. RETENTIONFEE: .�m�r�-;+v.r �j,�� §�a,l�k���'��' .^R".TgI � a CONSTRUCTIONLENDINGAGENCY ����—� g �d�� PRE-ALT FEE: aro.�?qS� �i�L� � IHEREBYAFFIfiMUNOEflPENqLTVOFPERJURVTHATTHEREISACONSTFUCTIONLEN�INGAGENCY '�y�����a � FORTHEPERFORMANCEOFTHC-WORKFORWHICHTHISPEflMITISISSUEO(SEC.3oW,CIV.C.�. Z W � LENDER'S NAME h_ LENDER'SADORE55 // � ICER7IGVTNATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORIAATIONISCOPRECT. TOTAL FEES f Y- d � I AGREE TO COMPLY WITH ALL CIN MJO C011NiV ORDINANCES AND STATE LAWS RELATING TO BUILDING r CANSTAUCTION,AND HEflEeY AUTHORIZE REPRES'cNTATIVES OF THIS COUNTV TO ENTER UPON THE �. � ABOYE-MENTIONEDPflOPERTYFORINSPECTKKJPVRPOSES. COMMENTS � J dt—,i/z..� 1//,� � m PERMITTEEN (RINT) ¢ �o .���-o0 � y SIG 7 EOPP MITTEE DATE - = RECPT.NO. 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